Provider Demographics
NPI:1376595991
Name:BIRDWELL, RUSS DEACON (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSS
Middle Name:DEACON
Last Name:BIRDWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3600 SHIRE BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-2240
Mailing Address - Country:US
Mailing Address - Phone:972-487-6400
Mailing Address - Fax:972-487-1686
Practice Address - Street 1:3600 SHIRE BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-2240
Practice Address - Country:US
Practice Address - Phone:972-487-6400
Practice Address - Fax:972-487-1686
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXG71405208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX105418103Medicaid
TX105418103Medicaid
TX8922MOMedicare PIN